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One of the main reasons people tend to like PPOs, unless they've had a good HMO experience, is the freedom to choose which doctors they go to. You can see someone contracted with your health plan, or not. If they aren't contracted, you pay more of the cost. And there is no 'discounted,' contracted rate to help contain your costs.

So when Covered CA came out this year and dictated that even if you have a PPO you will be assigned to a primary care provider (PCP) agents were very alarmed, because we knew the phone would start ringing. No, you still have a PPO, you just have a PCP to go with it. Here are the points, good, bad or indifferent, that you need to know about this new thing for 2017:

You will automatically be assigned to a PCP. Maybe it's someone you know, maybe not. The carriers are saying they may review claim info to try to assign you to someone that you've been using.

You don't have to use that doctor EVER--the theory is, maybe there will be a higher utilization of preventive services if a member has someone to go to, since a lot of people don't have a regular doctor. If you want to change your assigned PCP, just like with an HMO, you can at any time.

You can still go to anyone you want, you don't need a referral for a specialist--BIG difference from an HMO PCP.

This doctor supposedly is NOT being paid to be your PCP. With HMOs your PCP is paid 'capitation'--$X amount per member, per month, whether they see you or not. So the new PPO PCP, they will be compensated like they are now, when they see a patient.

So, is this going to make a difference, will it increase the use of preventive services? Dunno. Is it going to improve the quality of care? Maybe. Are patients and doctors going to like this? Remains to be seen. Just another change in our health care system that supposedly wasn't going to change once the ACA hit. So stay tuned....

Okay, it's hit the news, yes my phone is ringing, and yes the email volume is definitely up. Nightly news came out yesterday talking about how rates were going to be going up 25% in 2017. This is true, and some are going up more--I have clients whose rates are going up as much as 35%. So now what?

Covered California, the health benefits exchange here it the Golden State, has been saying that the average rate increase is just over 13%, but that's okay, because about 90% of consumers received financial assistance. That's not what I'm seeing, nor my peers. While Covered CA is putting out a good effort, the reason why there's such a high number of enrollees that are subsidized is that most agents only put cases through Covered CA if their clients are potentially eligible for assistance. Otherwise, it's a more lengthy application to do, and there have been problems. Definitely an improvement over the fall of 2013 when this insanity started, but there are problems.

I'm being challenged on that statement by some, about subsidies, but I know how I do things, and a lot of my agent peers. And I've not seen the math on this 13% 'average' number. Is that factoring in the new MediCal enrollees, most of whom don't have a payment, not sure. But when you have a plan that is offered both on and off Covered CA, by state law, it has to be 'the same'--meaning same benefits, same network and same rate. So why are the 'off exchange' plans so high? Whether they are on and off exchange plans, or off exchange only, things are shooting up.

Long story short, you have to 'shop' your plan. We have fewer choices, but check with an independent agent in order to be sure you aren't paying more than you have to.

When a call starts like this, it’s rarely good. This usually means someone has something wrong, or someone’s pregnant.

Problem
is, the intent of Health Insurance is in case something goes wrong. If
something has already happened, you don’t need insurance, you need financing and
insurance companies don’t classically do that. This whole idea is why requiring
people to buy insurance unfortunately is going to be important if health
care reform is going to work. Otherwise, what will happen is people
will only apply when they have an issue, then drop coverage when all’s
well. The concept of insurance, all types of insurance, is that people
have to pay in whether they need it or not then there is money in the
risk pool for when something is needed. And a risk pool is never
something you want to be in the shallow end of, that’s for sure.

This makes the open enrollment season more important than ever. Before 2014 we didn't have this in individual health insurance, just group health insurance with your employer. Now, you can enroll between November 1st and January 31st, but that's it. Unless you have a 'qualifying life event,' like getting married or divorced, having a baby, moving into a new service area where you existing plan won't work, losing a job or your company dropping their group health plan. Those situations, and few more obscure, give you a 'special enrollment period,' where you can enroll outside of open enrollment, but generally you only have a 60 day window.

My
main point is, we can’t close the barn door after the horse is out, so
that’s why you need health insurance. Before something happens!

Well, okay so your broker doesn’t have to be physically down the
street, but it’s looking more and more like getting some help in sorting
out options from someone when shopping for health insurance, available
to you at no cost, makes sense. Seriously--agents are paid by the carriers they place the business with, you aren't charged for it.

Several articles talk
about rates had shooting up and and people looking for new coverage.
Often people found working with an independent broker helped find
something manageable. You can go to the big major online sites but
honestly, the past few years, I’ve helped people change plans several
times after they bought something online then found it didn’t work the
way they expected.

The California Small Business
Association (CSBA) which I’m a member of has a program titled Buy
California Small Business First which is aimed at drawing attention to
doing business with people and companies within California. The reason
to do this is to keep more money/revenue in the state; it’s not
necessarily more expensive to do business with local smaller stores.
Now obviously not all insurance companies are based within California,
but the local broker is. You will most of the time end up with more
personal service when working with a broker. And if you don’t, then you
need to look elsewhere; there are thousands of us.

The
point is with health care reform in full bloom, there is way too much to
keep track of and relying on your broker to help you where needed can
be a real plus. Rate increases are hitting–and HARD this year. we don’t have all the
information yet like we have in years past but do you want to sit on
hold with Anthem Blue Cross or any other carrier for 20-30 minutes? I’m already
doing it, so just add you question to my list. It’s all about trying to
save clients money on their health care coverage where we can while
making sure as close as we can that your needs are met-–that what we do.

It's that time again, the Medicare Annual Election Period (AEP) where you
can make changes to the plans that augment your Medicare--which one is best,
which one will do the most for you, how do you decide? All of those blasted
Medicare related commercials, what are you to believe?

The Medicare AEP is when you can make changes to your Medicare Advantage
plans or Part D drug plans. AEP starts October 15th, ends December 7th, with
any changes you make taking effect January 1. This does not apply to Medicare
Supplements, not sure why, but they are regulated differently--my opinion
wasn't sought. We'll talk about that in another article.

Medicare Advantage plans--These will fill in some of the gaps on your
Medicare, and most will include your Part D drug coverage. Most of these are
HMO plans if you're in Southern California, and if you're in Los Angeles
County, several of the Medicare HMOs have no premium above your Part B premium.
These can be really cost effective options--some have no office visit or
hospitalization copays--wow! The potential drawback? They are HMOs, so you have
to stay within a network. If you are used to commercial (under age 65) HMOs,
these could be a good way to go if your preferred doctors are contracted.
Medicare HMO network can be larger than commercial HMOs because doctors are
realizing their patients are getting older.

Medicare PPOs--there are some but they are fewer and farther between. These
are part of the Medicare Advantage series of plans. And most of the time, like
commercial PPOs, you can count on more out of pocket expenses, even if you stay
'in network,' that's just the nature of the beast.

Part D drug plans (PDPs)--If you have a Medicare Advantage plan (HMO
or PPO) you usually do NOT need a drug plan, it's included in the plan. In fact
if you try to enroll in one, it will kick you out of your Medicare Advantage
plan. You will need a PDP if you have a Medicare Supplement because those do
not cover drugs. There are about 25 PDPs in California, and which ones will fit
your needs best depends on your medications and your preferred
pharmacy. It's definitely case by case.

Bottom line--work with an independent agent. There is no cost to you
with an independent agent. In order to make recommendations, we do the work of
checking out who your doctors are contacted with, which plans will cover your
medications best, at least that's what I do and my agent peers as well. You can
do it all on your own, call each carrier, try to decipher all the information
and pick a plan. And while the carrier reps are nice people for the most part,
they will all try to call you back to follow up. Aetna, Anthem, Blue Shield,
Silver Script, Health Net, AARP/United Healthcare, Humana and SCAN--all will
call you back. Work with an agent you like and trust, and just have one person
calling you back rather than several. After all, you have better things to
do with your time!